According to the National Institutes of Health (NIH), more than three million people in the United States - about one in 133 people - have celiac disease, a genetic disorder that causes an autoimmune reaction to gluten, a protein found in wheat, barley and rye grains. When these people eat foods that contain gluten, their immune systems react by destroying the tiny protrusions called villi that line the small intestine and allow nutrients to be absorbed into the bloodstream.

"Celiac disease can be debilitating because it prevents the body from absorbing nutrients properly, which can affect the whole body since the person becomes malnourished," says Kimberlee Alvari, R.D., Director of Food and Nutrition Clinical Services at Washington Hospital.

Some people with celiac disease - especially infants and young children - may experience digestive symptoms such as abdominal pain and bloating, chronic diarrhea or constipation, vomiting and weight loss. Adults generally are less likely to have digestive symptoms, but may experience symptoms such as unexplained fatigue, bone and joint pain, or an itchy rash called dermatitis herpetiformis. And some people may not experience any symptoms for years, until they develop complications of malnutrition such as anemia and osteoporosis.

"Up to 40 percent of adults with celiac disease may not have symptoms, but the disease could still be causing damage," says Alvari. "In addition to people who have celiac disease, there are millions more people who have non-celiac gluten sensitivity, which may produce irritating and uncomfortable digestive symptoms. It's important for people who suspect they may have celiac disease or gluten sensitivity to consult their doctors, especially if they have a family history of celiac disease, since it is a genetic disorder."

Currently, the only treatment for celiac disease - and gluten sensitivity - is to follow a gluten-free diet. There are no medications or surgical procedures to treat the disease.

"The Food and Drug Administration is still working on issuing a definitive definition of what constitutes 'gluten free,' but it generally means not eating foods that contain wheat, rye and barley," Alvari says. "That can be more difficult than it sounds, since many processed foods contain these grains or may be contaminated by traces of those grains. Even some rice cereals contain 'malt flavoring,' which is made from barley."

People with celiac disease generally must avoid most breads, pastas and cereals, as well as many processed foods.

"Fortunately, you can still have a well-balanced diet by consuming a variety of other foods," Alvari explains. "For starters, try to eat 'cleaner,' with fresh foods rather than processed foods that could have 'hidden' gluten. Chose plain meats, poultry and fish, instead of 'breaded' varieties. Include plenty of fresh fruits and vegetables. Include other grains in your diet, such as corn, rice, quinoa, flax and buckwheat - which is not really wheat. Potato flour and cornstarch are good to use in sauces and gravy. You might want to be wary of oats initially, since they may cause problems for some people, especially if have been processed in a factory that produces other grains."

Alvari notes that many more "gluten-free" products, including breads and pastas, are now available in stores everywhere than there were several years ago, making food choices easier for people who must avoid gluten. In addition, the Food Allergen Labeling and Consumer Protection Act of 2006 requires food labels to clearly identify wheat and other common food allergens in the list of ingredients.

"The best thing you can do is to seek the guidance of a dietitian who can help you learn how to read ingredient labels properly," she says. "A product label might not specify that it is gluten-free, but it may be. You also may want to consult your doctor about whether you should be taking a good broad-spectrum multivitamin, since gluten-free diets may result in nutrient deficiencies such as absorption of calcium, vitamin D, iron, and the B-vitamins folate, riboflavin and niacin."

People with celiac disease who wish to consume alcoholic beverages also must exercise caution. "Beer should be avoided, since it contains barley malt," Alvari explains. "Many hard liquors also may be grain-based. Wines are often gluten-free, but it's best to check with the vintner first."

One of the biggest challenges remaining for people who need to stick to a gluten-free diet is dining out at a restaurant.

"Years ago, you couldn't even find a gluten-free option on a restaurant menu," Alvari observes. "Things are better now, but it's a good idea to call ahead before going to a restaurant to see if they offer gluten-free dishes. You also should ask if they use separate equipment for preparing gluten-free food items. At Washington Hospital, we use separate equipment for our gluten-free foods to avoid contamination from other foods we prepare. I believe restaurants will be moving toward providing more gluten-free options soon."

Washington Hospital's Outpatient Nutrition Counseling program is available by appointment to provide nutrition counseling for individuals with specific medical needs. All nutrition counseling requires a physician referral. For more information, call (510) 745-6542.